What are the symptoms and treatment options for angle glaucoma?

Symptoms and Treatment of Angle Glaucoma

The characteristic symptoms of acute angle-closure glaucoma include blurred vision, halos around lights, eye pain, headache, eye redness, corneal edema, a mid-dilated pupil, and potentially nausea and vomiting, which require immediate medical attention to prevent vision loss. 1

Types of Angle Glaucoma

• Primary angle-closure disease (PACD) is characterized by appositional or synechial closure of the anterior chamber angle 1
• Modern classification includes:
  • Primary angle-closure suspect (PACS): ≥180 degrees iridotrabecular contact (ITC), normal intraocular pressure (IOP), and no optic nerve damage 1
  • Primary angle closure (PAC): ≥180 degrees ITC with peripheral anterior synechiae (PAS) or elevated IOP but no optic neuropathy 1
  • Primary angle-closure glaucoma (PACG): ≥180 degrees ITC with PAS, elevated IOP, and optic neuropathy 1
  • Acute angle-closure crisis (AACC): occluded angle with symptomatic high IOP 1

Clinical Presentation

Symptoms of Acute Angle-Closure Crisis

• Pressure-induced corneal edema (experienced as blurred vision and halos around lights) 1
• Eye pain and headache 1
• Nausea and vomiting 1, 2
• Decreased vision 1

Physical Examination Findings

• Mid-dilated, poorly reactive pupil 1
• Conjunctival hyperemia (redness) 1
• Corneal edema 1
• Shallow anterior chamber 1
• Very high intraocular pressure 1, 2
• Iris abnormalities including diffuse or focal atrophy 1
• Lens changes, including cataract and glaukomflecken (patchy, localized, anterior subcapsular lens opacities) 1

Risk Factors

• Asian descent 1
• Hyperopia 1
• Older age (typically over 50 years) 1
• Female gender 1
• Short axial length 1
• Thick and anteriorly positioned crystalline lens 1
• Shallow anterior chamber depth 1
• Steep corneal curvature 1
• Family history of angle-closure glaucoma 1

Treatment Algorithm

For Acute Angle-Closure Crisis (Emergency Management)

1. Initial medical therapy to lower IOP and relieve symptoms 1:

   • Topical beta-adrenergic antagonists (e.g., timolol) 1
   • Topical alpha2-adrenergic agonists 1
   • Topical, oral, or intravenous carbonic anhydrase inhibitors (e.g., acetazolamide) 1, 3
   • Topical parasympathomimetics 1
   • Oral or intravenous hyperosmotic agents if necessary 1

2. Definitive treatment once IOP is controlled 1:

   • Laser peripheral iridotomy (LPI) - the preferred surgical treatment 1
   • Surgical iridectomy if laser cannot be performed 1
   • Laser iridotomy in the fellow eye to prevent AACC 1

For Chronic Primary Angle-Closure Glaucoma

1. Laser peripheral iridotomy (LPI) to eliminate pupillary block 1
2. Post-iridotomy management if IOP remains elevated 1:
   • Topical ocular hypotensive agents 1
   • Laser iridoplasty if plateau iris is present 1
   • Lens extraction - particularly effective for PAC and PACG 1
   • Incisional glaucoma surgery if medical therapy fails 1

Important Considerations and Pitfalls

• Delayed diagnosis can lead to permanent vision loss: 18% of eyes may become blind and 48% may develop glaucomatous optic neuropathy within 4-10 years following an untreated AACC 1
• Verify iridotomy patency: After LPI, confirm that the iridotomy is patent by visualizing zonules, anterior lens capsule, or ciliary processes 1
• Monitor for persistent IOP elevation: Following LPI, IOP may remain elevated due to trabecular damage, PAS formation, plateau iris syndrome, or other causes 1
• Be aware of medication contraindications: In angle-closure glaucoma, timolol should not be used alone as it has little effect on the pupil 4
• Consider lens extraction: Growing evidence shows that cataract extraction alone may lead to substantial IOP lowering in PAC and PACG patients 1
• Recognize plateau iris: Some patients may have plateau iris configuration (narrow angle with deep central anterior chamber) that persists after iridotomy 1

Follow-up Care

• Confirm patency of iridotomy 1
• Measure IOP 1
• Perform dark-room gonioscopy with compression/indentation to assess the extent of PAS 1
• Examine the fundus as clinically indicated 1
• Prescribe topical corticosteroids in the postoperative period after laser treatment 1